Ensuring Access to High Quality Care in Revision Total Knee Arthroplasty: An Analysis of Referral Patterns and Clinical Outcomes at a Tertiary Care Center.

Abstract

Revision total knee arthroplasty (rTKA) volume is projected to increase by 149% by 2040 and 520% by 2060. While value-based payment models exist for primary TKA, similar quality initiatives are not currently in place for rTKA. This study aimed to characterize the patient population and referral patterns of rTKA patients at a tertiary care center and evaluate clinical outcomes based on referral patterns. We retrospectively reviewed 243 consecutive rTKAs performed by a single surgeon at an academic tertiary care center from 2012 to 2019. Patients were categorized by referral status: internal to the surgeon's practice (IS), internal to the hospital system (IH), or external (E). Demographics, revision history, indications, and outcomes, including re-revision rates and Knee Injury and Osteoarthritis Outcome Scores (KOOS), were analyzed. Multivariate logistic regression examined the effects of referral status and prior revision history on outcomes. External referrals comprised 51.0% of cases, with 33.7 and 15.2% from within the hospital system and the surgeon's practice, respectively. External referrals were more likely to have prior revision history (45.3 versus 25.0% for IS) and travel further for care (41.3 ± 3.7 versus 12.0 ± 3.5 miles). Instability was more common in external referrals (33.1 versus 13.5% for IS). History of prior revision independently predicted re-revision at all time points, while referral status did not affect re-revision rates. Final follow-up KOOS scores were similar between external and internal practice referrals. Despite higher rates of prior revision in external referrals, outcomes were equivalent across referral groups at a tertiary care center. As prior revision history predicts subsequent failure, early referral to centers with appropriate expertise and infrastructure may optimize outcomes. Current reimbursement models should be restructured to account for surgical complexity and ensure continued access to high-quality revision care.